“As of yet, the situation hasn't become very difficult to handle. But the next 10-15 days will be very critical because by this time we will come to know whether the virus is being contained or whether it is going out of our hands."
India has reported more than 120 positive cases of Coronavirus (COVID-19) across the country, including foreign nationals.
Battling this deadly virus which has wreaked havoc in China, United States and Europe are doctors, nurses, health workers and local district administrations. Earlier this week, The Better India (TBI) spoke to some of those fighting on the frontlines, particularly doctors and those at the helm of district administrations to understand the steps they are taking to battle this deadly virus.
While one hospital in Rajasthan found a novel way to treat some of its patients, we also spoke to a district collector in Kerala to understand the administrative contours of battling this virus.
Novel Treatment Procedure
In a sensational development, the Rajasthan Chief Minister had announced on Sunday that three patients who had tested positive for COVID-19, including two senior citizens with comorbid issues, were treated successfully at the Sawai Man Singh Hospital in Jaipur.
Happy to share, 3 corona patients including 2 senior citizens wd comorbid issues at SMS hospital,hv bn treated successfully & their test reports are now negative.
My heartiest compliments to SMS doctors & staff for their commendable & dedicated service in treating corona patients
— Ashok Gehlot (@ashokgehlot51) March 15, 2020
Having seen the epidemic wreak havoc in China from January onwards, doctors at the Sawai Man Singh (SMS) Hospital had long geared up to the possibility of an outbreak on home soil. They have a seperate isolation hospital and a plethora of teams including consultants, professors, anaesthetists and critical care people involved in battling COVID-19.
When the first patient to test positive for the Coronavirus arrived – an Italian lady, all of them got together and strategised on the medical treatment, supportive treatment they would administer and what they would do in the event the patient has retroviral issues as well.
“COVID-19 is a type of an epidemic virus like SARS (Severe Acute Respiratory Syndrome) or MERS (Middle East Respiratory Syndrome). It has a structural similarity to both the above mentioned viruses. We looked up on all available medical literature. Our entire team of experts strategised that we should administer some antivirals that would reduce the replication of the virus. Ensuring the safety of our patients, having taken their consent, and closely monitoring their progress, we administered a combination of Lopinavir/Ritonavir, which are usually given as a second line of treatment for HIV, and coupled that with drugs meant for curing Swine Flu and Malaria,” says SMS Hospital Principal, Dr Sudhir Bhandari, in a conversation with The Better India.
After administering their treatment and close monitoring, they found that the 70-year-old Italian lady, alongside her 69-year-old husband and another 85-year-old patient who had arrived from Dubai, had all tested negative for Coronavirus. However, these patients still have concerns with their underlying conditions like a respiratory disease or kidney failure.
“See, this is a very preliminary observation, and we have shared this with the Indian Council of Medical Research, which approved our protocol. More testing is required,” he adds.
“Yes, ICMR has taken approval for use of second-line HIV drugs on COVID patients but this Lopinavir/Ritonavir combination therapy has been approved for emergency use among COVID-19 patients with moderate degree of severity with laid down protocols,” stated Union Health Minister Harshvardhan, in an interview with The Indian Express.
The decision to administer these antiretrovirals was taken after their conditions worsened, in addition to the higher mortality risks associated with older people. “The combination of antiretroviral drugs are meant to be administered only for patients having medical complications, hypertension and respiratory failure or if their condition is worsening,” says Dr Raman Sharma, a senior professor of medicine at the SMS Hospital, speaking to TBI.
Thus far, they have tested 400+ eligible patients, of whom four had tested positive among international tourists, those they came into contact with here and their family members.
“For any person found to be COVID-19 positive or those suspected to have the virus, we take into consideration all the places they visited like shops, malls, export houses, restaurants and even the driver who ferried them or a hotel bell boy who unknowingly came into contact with the subject. We are blessed to have an intense contact tracing programme run by the Government of Rajasthan. See, the state sees the arrival of a plethora of tourists, but we have managed reasonably well so far,” says Dr Bhandari.
More importantly, there is a protocol for testing. No one can merely walk into the hospital and get themselves tested. Testing facilities are only available for symptomatic individuals at SMS Hospital. Only those who have come into contact with positive COVID-19 patients, returned from identified high-risk countries or have symptoms of fever, cough and breathlessness should get tested, reaffirms Dr Sharma.
How a District Battles COVID-19
Meanwhile, in another corner of the country, a district administration is all hands to the pump trying to contain the virus. Like other COVID-19 affected districts in Kerala, Kottayyam has worked overtime to ensure they have a handle on the epidemic. At the moment, they have two positive cases in the district receiving treatment at the Kottayam Medical College.
“There is a clear State government mandated protocol issued to each and every district to contain the virus. We are following that protocol. For example, we have to quarantine any primary contact (those in direct contact with the COVID-19 positive patient) for at least 14 days and more if they are particularly high risk. In case of foreigners who have come to India or the day they reach our district, we will be forced to quarantine them for 14 days irrespective of whether they have the virus or not. These tourists have come from among the approximately 120 high risk countries listed by the World Health Organization (WHO),” says PK Sudheer Babu, the district collector, speaking to TBI.
Two persons in Kottayam district who have tested positive had come into contact with their relatives from Pathanamthitta recently arrived from Italy. They too had tested positive.
“Upon their admission in the hospital, we began tracing their past movements by interviewing them, their relatives, mapping their movements by tracking their mobile phones using cell tower triangulation, Google Maps, identifying which places they visited and cross-checking it. We have marked each and every point they visited,” says the Collector.
“We issued a flowchart to the public so that they can inform us whether they were also present at the said locations and when they were there. We have mapped multiple points on the basis of that flowchart. From that we could identify at least 20 persons as primary contacts. We are identifying secondary contacts using the same practice. The administration has set up seven health teams on the field under the leadership of a medical doctor. They are cross-checking all the necessary information, interviewing all contact victims and through this extensive process we have identified more than 1,000 secondary contacts,” he adds.
The flow chart describes travel of two #COVID19 confirmed persons at #Kottayam during the days of February 29, 2020 to March 8. #CoronaOutbreak #COVIDScreening #CoronaVirusUpdate pic.twitter.com/YbLTTJ14w5
— Pratheesh G Nair (@PratheeshGN) March 12, 2020
These secondary contacts are under home quarantine. If they are symptomatic, the authorities will quarantine them in the hospital. Those who are asymptomatic, meanwhile, are at home. Only if they develop some symptoms are they brought to hospitals. Thus far, only 11 persons have been quarantined in the hospital, claims the Collector.
“Under the leadership of a medical doctor, our seven health teams conducting these contact tracing processes consist of trained professionals. We are adhering to all the necessary precautions for our health workers as per protocol. Meanwhile, we have launched the ‘Break the Chain’ campaign, which essentially urges all persons in the district who come into contact with some foreign object to wash their hands thoroughly. If they don’t have that facility they will be given hand sanitizers,” he informs.
In Kerala, the entire exercise is being coordinated by the Health Department with assistance from local self-governing bodies and the active participation of primary health centres (PHCs) in rural areas. The network of PHCs and ASHA (Accredited Social Health Activist) workers is strong in most parts of the state. Every ASHA worker knows each and every person in their respective areas, which makes tracing easier.
On the subject of testing, the Collector makes a reference to the guidelines issued by the state government, which is very similar to what doctors in Jaipur have said.
The epidemiology of COVID-19 shows that 75-80 per cent of the affected will develop only mild symptoms which do not require hospitalisation. Severe infection and mortality are seen only in high risk groups like elderly and those with chronic lung diseases, heart disease, liver disease, renal disease, malignancies, immunocompromised, pregnancy, post-transplant, hematological disorders, HIV and in those on chemotherapy and long term steroids.
“Just like any viral infection, COVID 19 also will resolve itself in the majority of the patients. Epidemiology of COVID-19, SARS and MERS clearly demonstrate that hospitals act as amplifying centres for the epidemic. This happens due to the mixing of patients with different risk categorization in the busy outpatient areas of designated COVID-19 centres. So patients with mild symptoms are advised not to come to hospitals for testing and treatment. Testing is not going to change either the clinical course or management of the patient with mild symptoms,” states the revised guidelines issued by the Kerala Government on March 12.
“Many foreigners complained that they needed a test report to fly back to their home countries, but if they are asymptomatic we cannot test them. Their results could delay the results of other patients who are actually symptomatic. Symptomatic cases samples are taken to a virology centre at National Institute of Virology in Alleppey,” says the Collector.
With all these measures taken, the Collector says that the situation hasn’t gone out of hand.
“As of yet, the situation hasn’t become very difficult to handle. But the next 10-15 days will be very critical because by this time we will come to know whether the virus is being contained or whether it is going out of our hands. This period is very important. We are putting a lot of efforts into containing it and preparing for any eventuality,” he claims.
While reported cases and mortality rates remain relatively low in India, it’s imperative that we don’t get complacent. Some argue that this is just the beginning of the epidemic in India, and the challenges that lie ahead could be enormous. In getting a small peek into how hospitals and district administrations are preparing themselves, we get an insight into the thankless task that lies ahead of them. However, a better way of showing them gratitude would be to follow prescribed precautions like washing your hands, social distancing, avoiding large crowds, responsible reporting of symptoms and allowing employees to work from home, amongst others.
If not adhering to these basic steps, we not only risk the health of others, particularly the vulnerable, but also place an immense burden on doctors, nurses, district administrations and health workers. Let’s not do that.
(Edited by Saiqua Sultan)